Anesthesia for Intracranial Aneurysm Surgery

Pekka O. Talke, MD

Aneurysms

2-5 % population 30K SAH/yr 2/3 get to hospital 1/3 in hospital severely disabled or dead Unruptured:1Unruptured:1-2%/yr rupture Ruptured: 50% rerupture within 6 mo

Urgent, not emergent cases

Surgeons
Lawton

Anesthetic Goals

Prevent aneurysm rupture (avoid hypertension) Decrease ICP (surgical exposure, retraction) Maintain CPP (>70 mmHg) Prevent cerebral ischemia from retraction Good operating conditions (NO movement, brain relaxation for exposure)

Patients, preop
Symptomatic/asymptomatic Ruptured (SAH grade, myocardial effects),

unruptured Possibly intubated Location and size of aneurysm Intracranial mass effect from SAH (increased ICP) Neurologic deficits and symptoms Timing, vasospasm

Preop
One IV Premedicate with up to 2 mg of midazolam if
normal mental status. Remind of potential post op intubation Adequate fluid loading (5 to 7 ml/kg of LR, angio)

Induction
Routine monitors Propofol or thiopental Fentanyl 5 ug/kg in divided doses prior to

intubation Muscle relaxant (roc). Arterial cannula before intubation Avoid hypertension (propofol) and hypotension (CPP, vasospasm)

Induction cont.

Ceftriaxone 1 gm, 4-10 mg decadron, 1 gm/kg mannitol. 4Tape eyes with tagaderms (prep solution) Temp probe, foley Additional IV (limited access, 300 cc to liters of blood loss) Compression stockings

Positioning
Supine, bump Long cases, lots of padding (pink and blue
foam) Table turned typically 90 degrees Head down?, aeroplaning After draping minimal/no access to face (secure ET well)

Maintenance
Oxygen Propofol infusion (50-200 ug/kg/min) (SSEPs, EEG) (50 Inhalation agent (<0.25 MAC Isoflurane). Muscle
relaxation (vec, panc)

Moderate hyperventilation (ET CO2 30 mmHg) Euvolemia to 500 cc more (LR) Moderate hypothermia (34 oC)

Burst supression

When requested by surgeon Thiopental 125 mg (5 cc) doses Till 70-80% EEG burst supression 70Redose as needed Turn fentanyl infusion off Reduce propofol infusion rate Support CPP with phenylephrine infusion

Clipping

Temporary clips (golden) Permanent clips (silver) Aneurysm manipulation before clipping (bleed) Record clip on/off times Maintain CPP during temporary clipping Start closing, warming and more fluid loading after clipping

Toward the end

First indication of end of surgery when clip

aneurysm (60 min) Normalize CO2 once dura closed or earlier if lots of intracranial space Reduce propofol if possible, and titrate in labetalol

Toward the end cont.

Turn propofol infusion off about 10 min
before wakeup Reverse relaxation once Mayfied pins have been removed Attempt to wakeup patient. Unlikely if more than 1 gm of thiopental given.

Recovery
Wake patient up as soon as possible Extubate if possible Prevent post op hypertension (bleed).
Labetalol

Transport to ICU with monitor and oxygen Head up position

Potential Complications
Delayed awakening from anesthesia Cerebral ischemia (retraction, temporary
clips, vasospasm)

Brain swelling Intraoperative hemorrhage

Aneurysm rupture
Reasonably common Intubation, pinning, skin insicion, surgical
manipulation

Maintain intravascular volume (blood in the room,

get help)

Maintain CPP Adequate anesthesia Thiopental before temporary clipping

Vasospasm
Only if SAH 5-14 days after SAH Leading cause of SAH morbidity (infarct) Maintain CPP at all times (neo infusion, volume) HHH therapy Consider CVP measurement

Whats new?
Retractor pressure Temp control Normotension

Surgical Steps

Mayfield pins (stimulation), head positioning Shaving/prepping/local anesthesia Skin incision (stimulation, blood loss) Scalp off the bone (most stimulation) Burr holes, sawing Removing bone Open dura Surgical approach to aneurysm (microscope, minimal stimulation, retraction)

Surgical Steps cont.

Burst supression Temporary clips, permanent clip(s) Close (60 min) Dura (water tight) Bone flap Scalp and skin Dressing, remove pins